Troponin leak and pressor of choice.

  1. Long story, semi short. 60 some yr old guy with a hx of cabg x 2 and chole admitted for syncopal episodes at an OSH. Patient was over there for a month runs into aki requiring dialysis and cvvh. Kidneys recover, liver fails - ercp x 2. Pt trached and finally sent to us for further management. Was sedated with Ativan up until 1 day before tx, trached and receiving tpn. Guy has intermittent runs of vtach, send full of labs. Troponin = 6.40, who knows if it was even checked at the OSH. They weren't checking his ammonia levels. Initially on norepinephrine at 10, sicu wants vaso and wean norepinephrine... I leave him w vaso on and Levo at 6. What is the pressor of choice for a troponin and guy requiring pressors for maps > 60???
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    About MLB55

    Joined: Mar '11; Posts: 83; Likes: 25
    NeuroICU; from US


  3. by   RNerd81
    IABP, what does the Echo show, ?inotrope, albumin, fluids. Sounds like an ECMO pt in the making...if there's anything left neurologically.
  4. by   MLB55
    No iabp, echo was pending at our hospital as he was admitted < 12 hours. Trop was not drawn on night shift, I added the trop after the runs of vtach he had been having since he got there. ended up giving him 500 x 2. The cabg and chole were just his hx. Last cabg was ~ 2 yrs ago. Pt is neurologically there. Very encepholopathic and a months worth of Ativan, but nodding appropriately and able to wiggle toes and fingers to command.
    Last edit by MLB55 on Jul 30, '12
  5. by   tri-rn
    Wondering about the rest of his picture. Was he making urine, did he look dry? did the 1L bolus help anything? The levo could make him irritable and hence the vtac - how were the rest of his 'lytes? Why couldn't they get him off the vent and why was he on it in the first place? Depending on when his blood was drawn in relation to the ectopy, the vtach could have contributed to the high troponin.
  6. by   MLB55
    Guy was making ~30m an hour of urine. K =4.3 credit. Cr = 1.6 appeared to be his new baseline. He responded to the fluids, urine picked up.
  7. by   MLB55
    Mag was normal, phos was a tad high, liver fx was high, blood gasses were metabolic acidodic, wbc was 20 something, hbg close to 10
  8. by   MLB55
    He was tx to us after a month of being vented and on ativan. Ativan was shut off before tx. Followed commands by nodding and wiggling, failed a sbt as his tv were 100 x 40, for us. Was with us less than 24 hrs.
  9. by   tri-rn
    The high WBCs, esp with metabolic acidosis, and low pressure make me wonder if he was septic. If he was, levo would be the pressor of choice (along with fluids). But that's just a wild guess based on limited info.

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